Packages of Care for Schizophrenia in Low- and Middle-Income Countries

In the third in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Jair Mari and colleagues discuss the treatment of schizophrenia

Review of methods used by chiropractors to determine the site for applying manipulation

Background: With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation. Methods: Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation. Results: A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement. Conclusions: A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.https://doi.org/10.1186/2045-709X-21-3

Exploring gender differences in the working lives of UK hospital consultants

Objective: Internationally, increasing numbers of women are practising medicine. Gender differences in doctors’ working hours, specialty choices and communication styles are well documented, but studies often neglect contextual factors such as the role of socialised gender expectations on behaviours in the workplace and the medical profession. These may be important as recent studies have reported gender differences in doctors’ activity rates that cannot be explained by specialty or contracted hours, suggesting other sources of variation. This study sought to explore the working lives of hospital doctors and how their work is negotiated according to gender and context. Design: Gender differences in the day-to-day work of hospital specialists (consultants) in the NHS were investigated using a qualitative approach, including observation and interview methods. Data were analysed inductively using qualitative observation and interview methods. Setting: Two NHS hospital trusts in England. Participants: Data were collected from 13 participants working in a variety of specialties and in a range of clinical and non-clinical settings.Main outcome measures: Various behaviours, attitudes and experiences were explored, such as doctor–patient communication, interactions with colleagues and workload. Results: Influences at both individual and situational levels, appear to affect differentially the work of male and female doctors. Female consultants described awareness of the impact of behaviours on relationships with colleagues, and their interactions appeared to be more carefully performed. Nurses and other colleagues tend to demonstrate less cooperation with female consultants.Gender differences also exist in patient communication, feelings of work–family conflict and barriers to career progression. Conclusions: These variations in hospital consultants’ work may have implications for both the quantity and quality of care provided by male and female consultants. This is timely and of importance to the medical workforce as the gender composition approaches parity